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A few months before World Breastfeeding Week (WBW) was celebrated across the world, the World Health Organisation (WHO) released a startling report exposing the “inappropriate and insidious” marketing tactics that formula manufacturers use to convert mothers to formula feeding.

WBW was held from 1 to 7 August under the theme “Step up for breastfeeding – educate and support”.

The far-reaching, negative impact of these tactics is compounded by the fact that they are in direct violation of the global best-practice guidance provided by the International Code for the Marketing of Breastmilk Substitutes, as well as the protections afforded by South Africa’s Regulations Relating to Food Stuffs for Infants and Young Children (R991). 

In celebration of national Breastfeeding Awareness month, the DSI-NRF Centre of Excellence in Food Security’s (CoE-FS) Food Imbizo hosted a webinar on, “Stepping up: exposing infant formula marketing tactics”. What was made abundantly clear by the keynote speakers is that mothers are being fed misinformation about the nutritional benefits that formula holds for their babies and young children. This is used to convince pregnant women and mothers that formula feeding is equivalent — and at times better — than breastfeeding. The webinar also explored the ways in which to educate and support breastfeeding mothers in South Africa.

The two keynote speakers were Professor Tanya Doherty, chief specialist scientist at the South African Medical Research Council and extraordinary professor in the School of Public Health at the University of the Western Cape; and Dr Chantell Witten, the project lead of the Infant and Young Child Feeding Advocacy (IYCF) project within the CoE-FS. Through the IYCF Advocacy project, counteractions to address the undue influence of the formula industry on women’s infant feeding decisions will be explored.

Unpacking recent reports

Professor Doherty discussed the findings of the multi-country study, which included South Africa, and was commissioned by the World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) to understand women’s exposure “to and experience of formula product marketing”. The study also drew on feedback from doctors, nurses, family, friends and partners, who influence women’s decisions about formula feeding, and culminated in a report.

“We know that the feeding practices of children in the first three years of life profoundly affect their survival, their wellbeing and their development throughout their life course,” said Doherty.

Close to a million cases of childhood obesity can be attributed to babies not being breastfed, as well as the deaths of 595 379 babies and young children between six months and five-years-old whose deaths could be attributed to developing diarrhoea and pneumonia because of not being breastfed.

“Yet, between 2005 and 2019, the sales of standard, follow-on and special formulas increased from 64% to as much as 214%.

“Over the same period, the rate of exclusive breastfeeding in 83 low- and middle-income countries improved from 25% to 39%. What we are seeing is that we have very little improvement in breastfeeding at the same time as we’re seeing enormous growth in sales of formula milk,” said Doherty.

The drive by academics focused on infant and young child nutrition in South Africa to improve breastfeeding rates in the country was not to limit women’s choices or contest legitimate reasons why some women do not breastfeed, said Doherty. Instead, it is to expose the way in which companies market formula milk, to “protect the right of women and their families to receive impartial information and support”, instead of “misleading false scientific claims” around infant and young child feeding, and in the “interest of broad public health over the interests of company profits”.

Myths and exposure

Across all eight countries, the study reported that women expressed a strong desire to breastfeed. However, in South Africa, only 51% of pregnant women indicated that they intended to breastfeed; the lowest of all participating countries.

“… marketing messages reinforce these myths around breastfeeding and breastmilk, particularly that formula is necessary in the first few days after birth because there’s insufficient breastmilk,” said Doherty.

Of the 8 528 pregnant and postnatal women surveyed in the study, 51% reported seeing or hearing about formula milk in the preceding year. Women from China reported the highest exposure at 92%.

In South Africa, where the R991 prohibits advertising and promotion of formula products “in any form, and on all media platforms”, self-reported exposure to formula marketing was at 21%. However, with only 32% (the UN nutrition target is 50% by 2025) of women in South Africa breastfeeding, the formula feeding population remains high, with a third of local women surveyed indicating that they purchased formula brands based on whether it was “good for the baby’s health” and the “closest formula to breastmilk”.

Targeting health professionals

Health professionals are also being targeted by the industry, with one mother writing that her doctor had told her to “use [formula] as it is light” and “tantamount to giving [her baby] breastmilk”.

In their interviews for the WHO study, South African health professionals admitted that this was true, and that many of them were now recommending formula to mothers. One such interviewee, a doctor, said they had “millions of pamphlets”, and that the formula industry would “push their products through me”.

Dr Witten added that the formula industry engages with healthcare professionals through institutions of training, and by funding academics and/or their research. These health professionals, in turn, have access to mothers through antenatal and postnatal care, immunisation contact points, and when their children are ill. Families, said Witten, also value the use of formula as most mothers are single, working women, or are unemployed and need to look for work every day.

“Formula feeding then becomes the solution for mothers who are separated from their babies,” said Witten.

Milking mothers’ insecurities

For her presentation, “Infant formula industry milking mothers’ insecurities: building counteractions to the influence of the infant formula industry”, Witten focused on those influencing mothers’ feeding choices; R991 and its purpose, and what has been achieved in South Africa because of the legal framework; and how the general public can counteract the misinformation shared about the benefits of formula.

“… what we see is that women’s decisions are influenced by mainstream media, general society norms, and the narrative that is being portrayed and broadcasted is that pregnancy is difficult, birthing is difficult, breastfeeding is hard, and parenting is informed by science.

“That narrative flows into how the formula industry’s positions its products as science-based and specialised.”

Mothers are further undermined in their decisions to breastfeed, as marketing by the formula industry plays upon mothers’ insecurities and anxieties, and the narratives driven by family and friends who lack the necessary information.

This has led to the erosion of breastfeeding in South Africa and underlies child morbidity and decreases child health. The duration of breastfeeding of babies has also dropped from 16.6 months in 2003 to 11.6 months in 2016.

“That is not just about chasing targets, but about child health and child survival. So all our malnutrition — whether that is obesity in children or severe acute malnutrition — the underlying thing fuelling this is inappropriate infant feeding and that is fuelled by either formula feeding or feeding children alternatives.”

Awareness and accountability

For this reason, Witten and the rest of the IYCF Advocacy project research team are making a concerted effort to share their knowledge in mainstream media, as well as with child health and development professionals.

“We [need] proactive monitoring of violations and the enforcement of R991 regulations to push back on the formula companies whose tactics are hindering women’s access to unbiased information.”

In spite of the challenges, Witten believes that R991 has brought “significant victories” in South Africa.

Some of those victories include changes made in labelling, composition, and packaging of formula milk and the tins they are sold in. Companies are no longer allowed to use humanising graphics on formula tins and tins must clearly state that breastmilk is the best food for babies, and that their products do not contain breastmilk.

“Based on R991, anyone working in the health system can also be held to these regulations,” she added.

Witten cited the 2021 case where “nutrition and child health experts, together with health and children’s rights activists, condemned a marketing event planned … and sponsored by Nestlé”, preventing it from taking place and shining a light internationally on the marketing methods used by formula producing companies to reach mothers.

The WHO reports have also led to decisions by the British Paediatric Association and the American Academy of Pediatrics that they will no longer take funds from formula-producing companies.

“While the report from the WHO shows us that there are still some gaps in terms of how the formula industries are milking our moms, the attention that has been placed on academia is paying off and we are seeing that there is more support for breastfeeding.”

“When the whole of society gets behind the breastfeeding agenda … we can roll back formula feeding just like we did with the Prevention of Mother to Child Transmission programme … That’s the kind of energy we are looking for in terms of advocacy around improving and supporting breastfeeding in South Africa.”

To do this, every South African has to chip in to counteract negative breastfeeding narratives in the media, report health professionals that discourage mothers from breastfeeding, object to academic institutions taking funding from the formula industry, and being supportive of mothers in family circles.

“We need to actively use the media to create awareness of all the provisions of R991 to improve infant and young child feeding and build advocacy around R991, particularly for controlling the marketing of unhealthy foods, which includes formula.

“We also need to support the call for proactive monitoring and reporting [of contraventions] of R991,” said Witten, explaining that no sanctions or fines have been imposed as yet.

“We need to start looking at our public health profile, particularly with regards to rising childhood obesity and start thinking about financial sanctions against the marketing of obesogenic foods, which include formula.”

“As we all know, the foundation of a healthy flourishing nation lies in healthy flourishing children.”

Watch the webinar in full, here, or below: